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APPE Case Presentation
Samantha Allen
Pharm D Candidate 2012
March 14, 2012
JK was admitted on 2/22/12.
CC: JK is a 26 y/o male who presented to Miner ER because he was not feeling well.
HPI: He reported a 3 week history of myalgias, confusion, and arthralgias, as well as a 25 lb
weight loss. He complained of abdominal pain and pain in the upper quadrants of his abdomen.
JK was hypotensive and became more lethargic after he arrived to Miners and required
intubation. He was given sulfamethoxazole/trimethoprim, vancomycin, and ceftazidime for
suspected sepsis. Patient was thrombocytopenic with a platelet count of 60,000. Patient was
given 6 L of fluids and was transferred to Conemaugh.
PMH:
1. IV Drug Abuse (heroin)-Stopped approximately 4 weeks ago per mother
2. Possible DM
3. Positive Lyme Titer
SH: Remote history IV Drug Abuse, 1 ppd smoker, alcohol use unknown
FH: Not obtained
Home Medication List:
1. Insulin aspart sliding scale
Allergies: NKDA
Vital Signs:
T: 35.3ºC
BP: 106/68 mmHg HR: 81 bpm
RR: 19 rpm O2 Sat: 100% on ventilator
ROS: Unobtainable
PE:
General: Pt. is sedated, in no acute distress and is intubated.
HEENT: Normocephalic, atraumatic. Pupils 2 mm, reactive to light.
Neck: Supple, no nuchal rigidity. Trachea midline. No JVD.
Chest: Equal Expansion
Heart: S1-S2 heard, systolic murmur, grade 2/6, no rubs or gallops.
Lungs: Rhonchi heard bilaterally. No wheezing or crackles appreciated.
Abdomen: Positive bowel sounds. Soft, moderate spleen palpable. No rebound, no
guarding, nondistended, nontender.
Extremities: Trace edema, no cyanosis, no clubbing, no petechiae, no hemorrhages.
Neuro: Unable to assess.
Investigations:
-CT of the chest showed atypical pneumonia, with atypical consolidation noted at the lung bases
bilaterally, some areas of cavitation within consolidated areas. Noted to be pulmonary emboli in
the right lower lobe. Mediastinal left hilar adenopathy present.
-CT of the abdomen and pelvis showed moderately enlarged splenomegaly.
-CT head showed no acute intracranial pathology.
-CXR showed subclavian line in place, bilateral rhonchi.
-Labs:
WBC: 6.9x103/mm3
Hgb/Hct: 8.5 g/dL / 25%
LFTs: Bilirubin- 0.6 mg/dL AST-107 IU/L ALT- 29IU/L PT/INR- 14.4/1.4
LDL: 343 mg/dL
ABG: pH-7.35 PCO2-38 mmHg O2 Saturation-99.2%
Na: 129 mEq/L
K: 3.2 mEq/L
Cl: 104 mEq/L
Ca: 6.0 mg/dL
CO2: 17 mEq/L
Scr 0.6 mg/dL BUN 12 mg/dL
Lactic Acid 0.7 mmol/L
Mg: 1.8 mg/dL
Phos: 2.6 mg/dL
-Sputum culture: Gram (+) cocci (S. aureus), resistant to PCN-G
-Blood culture: No grow after 5 days
-Legionella antigen (urine): negative
-S. pneumonia antigen (urine): negative
-Hepatitis C Antibody: positive
-TEE: Large echodensity possibly attached to the septum moving in and out of the R atrium. EF
55%. Large 2.98 x 1.78 cm vegetation infiltrating anterior leaflet of tricuspid valve with mild
tricuspid regurgitation.
Problem List/Plan:
1. Sepsis likely secondary to IV drug abuse. Possible endocarditis. Atypical pneumonia
related to septic emboli and pulmonary embolism.
-Continue vancomycin and ceftriaxone. Initiate acyclovir in view of possible meningitis.
2. Acute respiratory failure secondary to sepsis and pulmonary embolism.
-Initiate propofol and continue mechanical ventilation. Begin heparin drip.
3. Moderately enlarged spleen with weakly positive mono spot.
4. Thrombocytopenia likely secondary to substance abuse.
5. Possible diabetes. Obtain AlC.
-Continue diabetic ICU protocol
6. DVT prophylaxis
-Continue SCDs
7. GI prophylaxis
-Famotidine
8. Nutrition
-On D5W/NS w/ 3 amps bicarb.
Events of last 24 hours:
Surgery 2/23/12:
 Diagnosis- Tricuspid valve endocarditis with tricuspid and right atrial vegetations with
septic pulmonary abscesses with respiratory failure.
 Currently on a ventilator.
 Procedure- Excision of right atrial and tricuspid valve vegetations and replacement of the
tricuspid valve with 27 mm Carpentier-Edwards pericardial bioprothesis.
 Gram stain vegetation- Gram (+) Cocci
Vital Signs 2/23/12:
 Preoperatively- T: 34.7 ºC BP: 105/59 mmHg HR: 64 bpm
O2 Sat: 97% on ventilator
 Postoperatively- T: 35.9 ºC BP, HR, RR- Not documented
O2 Sat: 99% 4L nasal canula
RR: 11 rpm
New PE findings: Not documented
Investigations:
 CXR Preoperatively-NG tube removed, right subclavian catheter stable, right
endotracheal tube slightly retracted, decrease pulmonary edema, perisistent bibasilar
opacities probably reflecting atelectasis.
 CXR Postoperatively- Mild interval improvement in the aeration of both lower lungs.
Milds pulmonary vascular congestion.
 Tricuspid vegetation- Staphylococcus aureus
CLINDAMYCIN
ERYTHROMYCIN
GENTAMICIN
OXACILLIN
PENICILLIN-G
TETRACYCLINE
TRIMETH-SULFA
VANCOMYCIN
SUSCEPTIBLE
SUSCEPTIBLE
SUSCEPTIBLE
SUSCEPTIBLE
RESISTANT
SUSCEPTIBLE
SUSCEPTIBLE
SUSCEPTIBLE
Labs:
WBC: 11.1x103/mm3, 12% stabs, 83% polys
Hgb/Hct: 8.5 g/dL / 26%
Na: 146 mEq/L
K: 3.3 mEq/L
Cl: 112 mEq/L
Ca: 6.5 mg/dL
CO2: 22 mEq/L
Scr 0.7 mg/dL BUN 18 mg/dL
Complete List of Medications:
 Ceftriaxone 1 gm IV Q24HR
 Cefazolin 1 gm IV q8hr
 Vancomycin1 gm IV BID
 Famotidine 20 mg IV BID
 Enoxaparin 40 mg SQ QDay
 Aspirin 81 mg PO QDay
 Insulin (Novolin R) SQ PRN sliding scale
 Potassium chloride 20 mEq IV PRN
 Magnesium sulfate 4 mg IV PRN
 Midazolam 2 mg IV PRN
 Morphine 4 mg IV Q1-2HR PRN
 Temazepam 15 mg PO QHS PRN
 Oxycodone-APAP 5-325 mg 2 tablets Q4HR PRN
 Acetaminophen 650 mg supp Q4HR PRN
 Ondansetron 4 mg IV Q4HR PRN
 Milk of magnesia 30 mL QDay PRN
 Eye Lubricant (Lacri-Lube S.O.P) 1 application QID and QHS
 Polyvinyl alcohol 1.4% (Awka Tears) 1 drop QID
Problem List 2/23/12:
1. Tricuspid valve replacement
-Postoperative antibiotics: cefazolin 1 gm IV q8hr and vancomycin 1 gm IV BID
-Initiate aspirin 81 mg QDay
-Pain Management:
Acetaminophen 650 mg supp Q4HR PRN
Morphine 4 mg IV Q1-2HR PRN
Oxycodone-APAP 5-325 mg PO 2 tablets Q4HR PRN
-Insonmia: Temazepam 15 mg PO QHS PRN
-Electrolyte Management:
Potassium chloride 20 mEq IV PRN
Magnesium sulfate 4 mg IV PRN
2. Endocarditis likely secondary to IV drug abuse (S. aureus)
-Continue ceftriaxone 1 gm IV q24hr
3. DVT Prophylaxis
-Enoxaparin 40 mg SQ Qday
4. GI Prophylaxis
-Continue famotidine 20 mg IV BID
5. Blood glucose Management
-Insulin (Novolin R) SQ PRN sliding scale
6. Additional PRN Orders
-Ondansetron 4 mg IV Q4HR PRN for post-operative Nausea/Vomiting
- Milk of magnesia 30 mL QDay PRN for constipation
- Eye Lubricant (Lacri-Lube S.O.P) 1 application QID and QHS
- Polyvinyl alcohol 1.4% (Awka Tears) 1 drop QID
________________________________________________________________________
Discharge 3/7/12:
Discharge Medications:
 Nafcillin 12 gm IV in 240 mL 0.9% NaCl @ 10 mL/hr x 4 weeks
 Aspirin 81 mg PO daily
 Metoprolol 25 mg PO BID
 Ferrous sulfate 325 mg PO BID
 Multivitamin once daily
Discharge Plan:
1. Tricuspid Valve Endocarditis (Oxacillin sensitive S. aureus)
-Continue nafcillin 12 gm IV in 240 mL 0.9% NaCl @ 10 mL/hr x 4 weeks to complete 6
weeks of therapy
-Home health nurse to follow
-Follow-up with PCP in 1 week
-Follow-up with cardiology as scheduled
-Follow-up with surgery as scheduled
2. Bioprosthetic Tricuspid Valve Replacement
-Aspirin 81 mg PO daily
-Metoprolol 25 mg PO BID
-Continue cardiac diet
3. Iron Deficiency Anemia
-Ferrous sulfate 325 mg PO BID
-Multivitamin once daily
4. IV Drug Abuse
-Seek counseling
-Patient signed statement on discharge that he will not use IV drugs